Fetal Demise in the 2nd or 3rd Trimester

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This page has been edited 1 times. The last modification was made by - judithcbliss judithcbliss on Feb 21, 2015 2:33 pm

Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/amion, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.


History of 2nd or 3rd trimester Fetal Demise
Evaluation
  • Take a history and try to establish that the demise was prior to labor (not a neonatal loss during labor or due to prematurity). Make sure that the loss was after 12 weeks EGA—some first trimester losses are not discovered until the second trimester. The gestational age of the loss is the size of the fetus, not how long she has been pregnant.
  • Ask if a cause was found or suspected.
  • Try to establish for later gestations if the fetus was also small for the gestational age suggesting and underlying fetal growth restriction.
  • Get records if at all possible including autopsy, placental pathology and relevant blood tests.
  • Use the information to target your evaluation, e.g. if there were fetal anomalies or a placental abruption or known fetal CMV infection there is no need to do an extensive work up for other causes.
  • Keep in mind that the cause is often not determined and that the cause given to the mother may not be correct—e.g. cord around the neck might be present but not the cause of death.

Labs and Tests
  • Check TSH and make sure usual diabetes evaluation done
  • Consider maternal and paternal karyotype if recurrent or suggestion chromosomal abnormality
  • Recommend state screen testing including NT ultrasound
  • Recommend usual anatomy ultrasound. If history of anomalies or syndrome, consider genetic counseling and level II anatomy scan.
Acquired thrombophilia work up includes (may need to be drawn in Martinez):
  • Lupus anticoagulant
  • Anticardiolipin antibody
  • Beta-2 glycoprotein
If negative or history suggestive of thrombophilia in patient or family consider inherited work up:
  • Protein C
  • Protein S Ag activity
  • Factor V Leidin
  • Antithrombin III
  • Prothrombin Gene Mutation
Third trimester –e.g. 32 week growth ultrasound and attention to FH.
Low threshold for cholestasis of pregnancy evaluation (bile acids)

Prevention
  • Your goal is to make an extra effort to prevent a recurrence of the loss.
  • If cause unknown or associated with SGA, start ASA 81mg daily at 10-12 weeks EGA.
  • Start antepartum testing at 32 weeks and 2 weeks before prior loss, after 28 weeks.

Make a delivery plan
  • If not likely to recur (anomaly not present, CMV prior pregnancy, probable cord accident etc) may induce at or after 39 w0d if mother prefers induction (versus usual management) for emotional reasons.
  • If cause unknown or at higher risk of recurrence, especially if associated with SGA, consider induction at 38 weeks EGA, or occasionally earlier. Consult for delivery timing plan with OB on call or Perinatology
  • It is usual to call for consultation (OB Attending) or to schedule a consultation visit with the Perinatologist in one of the High Risk Pregnancy Clinics in Pittsburg, Martinez or West County.